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Cultural gynecomastia in the 21st century India: “Witch's milk” revisited
pediatria polska 91 (2016) 472–475
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/pepo
Case report/Kazuistyka
Cultural gynecomastia in the 21st century India: “Witch's milk” revisited Devi Dayal 1,*, Vimlesh Soni 1, Dhaarani Jayaraman 1, Lakshminarasimhan Sindhuja 1, Naresh Sachdeva 2 1 2
Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
article info
abstract
Article history:
Despite the common cultural practice of expressing breast milk in neonates, the resul-
Received: 23.03.2016
ting gynecomastia is rarely reported probably because it is considered benign and short
Accepted: 25.04.2016
lasting. To determine the clinical course of gynecomastia–galactorrhea resulting from the
Available online: 04.05.2016
cultural practice of expressing breast milk, we performed a retrospective analysis of data
Keywords: Gynecomastia
hospital over the past decade. The mean age at presentation and at the time of first
Galactorrhea Cultural practices
days) respectively. The average duration of breast manipulation was 39.0 66.9 days
of 20 infants (14 girls) diagnosed as cultural gynecomastia at a tertiary care pediatric
Witch's milk Neonatal breast manipulation
noticing was 8.0 9.3 months (range 0.25–27 months) and 54.6 93.9 days (range 2–365 (range 3–270 days). All infants cried during the process of breast manipulation. The mean age at complete resolution was 16.9 8.9 months (range 4–36 months). Gynecomastia resulting from the cruel cultural practice of milking of neonatal breasts exists in modern times and may persist for long time during infancy. © 2016 Polish Pediatric Society. Published by Elsevier Sp. z o.o. All rights reserved.
Introduction Enlargement of breasts occurs in approximately 70% of normal neonates and is considered physiological [1]. It is probably caused by hyperprolactinemia secondary to the falling levels of maternally transferred estrogens in the neonate [1]. The breast enlargement may considerably vary in size but the palpable breast tissue (PBT) usually measures <2 cm [2]. Hyperprolactinemia may also stimulate the
breasts to produce milk commonly referred to as “Witch's milk” [3]. These two physiological phenomena of breast enlargement and milk secretion are usually self limited but may sometimes persist till 2 months of age [4, 5]. However, repeated manual emptying of glands may result in continued milk secretion for up to 24 weeks, and significant increase in PBT which may persist for a variable period during infancy [5, 6]. Although manual expression of breast milk is common in many countries as an unhealthy cultural practice that probably had its origin from the superstitions
* Corresponding author at: Pediatric Endocrinology & Diabetes Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India. Tel.: +91 172 2755657/2772777; fax: +91 172 2744401/2745078. E-mail addresses: [email protected], [email protected] (D. Dayal). http://dx.doi.org/10.1016/j.pepo.2016.04.010 0031-3939/© 2016 Polish Pediatric Society. Published by Elsevier Sp. z o.o. All rights reserved.
pediatria polska 91 (2016) 472–475
related to witch's milk [6–9], reports on the clinical course of the resultant gynecomastia and/or galactorrhea are rare [6]. Also, it is not known if the PBT regresses completely or residual gynecomastia persists. With an aim to understand their presentation and follow up course, we retrospectively analyzed the clinic records of children diagnosed to have this condition at our center.
Materials and methods Cultural gynecomastia was defined as the occurrence of bilateral gynecomastia (average PBT >4 cm diameter) and/or galactorrhea as a result of cultural practice of milking of breasts of neonates of either sex [6, 9]. Data regarding the age the at time of noticing by parents and at diagnosis, number of days and reasons (custom/belief) of breast manipulation, diameter of PBT at presentation, pigmentation of areola and nipples, hormonal profiles if available, age at complete resolution, and presence of residual gynecomastia if any, were extracted from the clinic files. Those with unilateral gynecomastia, any evidence of infection or nipple discharge other than milk and a known etiology for prepubertal gynecomastia [10] were not included in the analysis. The educational and socioeconomic status (SES) of parents was recorded.
Results Twenty children who attended the Pediatric Endocrinology Clinic of our tertiary care teaching hospital located in Northwest India, between April 2004 and April 2015 were diagnosed to have cultural gynecomastia. Girls (14, 70%) outnumbered boys. The mean age at presentation was 8.0 9.3 months (range 0.25–27 months) and at the time of first noticing by parents were 54.6 93.9 days (range 2–365 days). The reasons for seeking medical advice were nonresolution of gynecomastia/galactorrhea, social embarrassment or parental anxiety regarding some underlying problem. The average duration of breast manipulation was 39.0 66.9 days (range 3–270 days). The exact reason for breast squeezing was not known to most mothers (14, 70%) who just followed the grandmother or the midwives’ advice blindly and performed this like a customary practice. Others (6, 30%) tried to suggest that they followed the custom due to the prevalent belief that breasts will not become prominent at the time of puberty which is considered indecorous in large families. The process of breast manipulation to express milk was considered to cause pain as crying during the process occurred in all infants. The mean PBT diameter at presentation was 4.4 0.4 (range 4–6 cm) on either side (Fig. 1). Pigmentation of areola and nipple was not seen in any patient. Galactorrhea was present in 15 (75%) patients. Hormonal profiles were obtained in 10 patients only, mainly on parental insistence. The mean levels of luteinizing hormone (LH), follicle stimulating hormone (FSH), estradiol (E2) and prolactin (PRL) were 0.71 1.8 mIU/mL (range 0.1–5.8 mIU/mL, normal 0.02– 0.3 mIU/mL), 4.9 3.4 mIU/mL (range 2.61–14.3 mIU/mL,
473
normal 0.26–4.2 mIU/mL), 14.2 14.8 (range 5.0–49.5, normal <30 pg/mL), and 17.8 10.8 ng/mL (range 7.7–39.4, normal 3–24 ng/mL) respectively. No intervention other than a firm advice to stop expressing milk was done in any patient. Repeat hormonal estimations after 3–6 months in 3 children with abnormal initial results (LH 2, FSH 2, E2 1, PRL 3) were within normal ranges. The mean age at complete resolution was 16.9 8.9 months (range 4–36 months). The mean duration of follow up was 25.1 11.9 months (range 12–55 months). Nine (45%) families belonged to lower, 10 (50%) to middle and 1 (5%) to upper SES. All mothers were educated up to primary (6, 30%), high school (4, 20%), secondary school (5, 25%), and graduation (3, 15%) or post graduation (2, 10%).
Discussion The cultural practice of manipulation of the newborn baby's breasts to express what is popularly called Witch's milk, is centuries old [3]. The twin phenomena of neonatal breast enlargement and milk secretion were first recorded in the 17th century at a time when superstitions prevailed over reasoning [3]. According to one superstition, some women were accused of having sold their souls to Satan in return for the gift of supernatural powers and were referred to as witches and believed to victimize babies by suckling their mammary glands and leaving the “Witches’ marks”. The custom of expressing milk from the neonate's breasts probably originated from the lingering superstitions regarding witch's milk [3]. Midwives and grandmothers believed that if witch's milk were not frequently and thoroughly expressed from the baby's mammary glands, it would be stolen by witches and goblins. Another belief was that the formation of milk from the babies’ breasts was induced by evil spirits, goblins, or imps to provide themselves with a source of nourishment, and that this bad milk must be sucked out [3]. In India, it is a customary practice to milk a neonate's breasts everyday from the age of 7 days up to the age of 7 weeks or until milk ceases to be expressed [6, 9]. It is believed that this expression of milk in the neonatal life does not allow the breasts to become prominent before the popular age for arranged marriage. Large breasts at an earlier age (usual age of onset of puberty) are considered inappropriate in extended Hindu families [9]. While this harmful cultural practice became extinct from the developed countries after the advent of modern science, it persists in the less developed countries even today [3, 6–9]. In a study from Jamaica on cultural beliefs and practices, squeezing of neonatal breasts to express milk was practiced by 52.2% of mothers [7]. In a recent series from North India, a prior history of manual expression of breast secretions was recorded in 15 out of 32 neonates who developed mastitis or breast abscesses [8]. Other authors from India have referred to this as a common practice especially in rural areas [11, 12]. Parents seek medical advice only if the gynecomastia/galactorrhea does not regress as expected, feel social embarrassment of having an infant with enlarged breasts, or develop anxiety about an underlying problem. Our patients also were brought after an average gap of
474
pediatria polska 91 (2016) 472–475
Fig. 1 – Infants aged 1–1½ yrs showing breast enlargement
approximately 6 months from onset of the condition. The affected babies belonged to all SESs and mothers’ educational status had little impact on this customary practice. The practice of milking the neonatal breasts is potentially harmful. Although infective complications were not noted in the earlier studies [5], recent reports suggest this practice to be a common underlying factor for development of neonatal mastitis or abscess [8, 11–14]. The infection is usually localized to breasts but may result in complications such as cellulitis, fasciitis, osteomyelitis, brain abscess and sepsis [11, 13]. Additionally, girls treated for neonatal mastitis as infants may show poor pubertal development of breast tissue [15]. The enlarged breasts during infancy cause social embarrassment and worry about an underlying etiology as reported by the parents. The persistence of gynecomastia till the mean age of 16.9 months in our patients was probably a result of continued breast stimulation. Cultural gynecomastia closely resembles isolated premature thelarche which is another common and usually
benign condition during early childhood [16]. A significant history of breast manipulation during early infancy and noticing of breast enlargement almost simultaneously or within a short period after manipulation, strongly favors a diagnosis of cultural gynecomastia. Additionally, cultural gynecomastia is usually noticed during early infancy as seen in our cohort of patients, as compared to isolated premature thelarche which is usually diagnosed after 2 years of age [16]. The practice is of breast manipulation is cruel to the infant as parents reported crying in all babies particularly when vigorous attempts were made in a bid to squeeze out the last few drops of milk from the breasts. The cumulative suffering of pain by the infant over many days or weeks is enormous and should also be perceived as a form of cultural cruelty. One of our patients had to suffer this for 9 months. The residual gynecomastia may be a source of low esteem in a growing child similar to the psychological effects of pubertal gynecomastia [17].
pediatria polska 91 (2016) 472–475
The lack of data on the cultural gynecomastia is intriguing given that the practice of milking of neonatal breasts is common in many countries. It is important to document information on this cultural practice similar to several other more harmful traditional practices that impinge on children's rights [18]. In addition, the evidence on existence and effects of the harmful practices is essential to develop legislative and other measures that will result in a sustained abandonment of such practices against children [18]. In conclusion, the cruel cultural practice of expression of breast milk in neonates exists in modern times and needs to be abandoned. The condition is not always benign and self limiting contrary to previous observations. To the best of our knowledge, this is the first detailed account of cultural gynecomastia from a developing country set up.
Authors’ contributions/Wkład autorów DD – concept and design, preparation of final draft of manuscript. VS – data collection, preparation of initial draft of manuscript. DJ – data analysis, editing and review of first draft of manuscript. SL – literature review, intellectual inputs during preparation of final draft. NS – interpretation of laboratory data.
Conflict of interest/Konflikt interesu None declared.
Financial support/Finansowanie None declared.
Ethics/Etyka The work described in this article have been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans; EU Directive 2010/63/EU for animal experiments; Uniform Requirements for manuscripts submitted to Biomedical journals.
475
references/pi smiennictwo
[1] Amer A, Fischer H. Neonatal breast enlargement. N Engl J Med 2009;360:1445. [2] Jayasinghe Y, Cha R, Horn-Ommen J, O’Brien P, Simmons PS. Establishment of normative data for the amount of breast tissue present in healthy children up to two years of age. J Pediatr Adolesc Gynecol 2010;23:305–311. [3] Forbes TR. Witch's milk and witch's marks. Yale J Biol Med 1950;22:219. [4] Madlon-Kay DJ. ‘Witch's milk’. Galactorrhea in the newborn. Am J Dis Child 1986;140:252–253. [5] Buehring GC. Witch's milk: potential for neonatal diagnosis. Pediatr Res 1982;16:460–462. [6] Devidayal. A male infant with gynecomastia–galactorrhea. J Pediatr 2005;147:712. [7] Tracey-Moodie J. Cultural practices and beliefs of mothers in St. Catherine, Jamaica and how these influence care of their newborn and the implications for the health system. MD dissertation abstract The University of the West Indies at St. Augustine, Trinidad and Tobago; 2001. Available at: http://hdl.handle.net/2139/3851. [8] Masoodi T, Mufti GN, Bhat JI, Lone R, Arshi S, Ahmad SK. Neonatal mastitis: a clinico-microbiological study. J Neonatal Surg 2014;3:2. [9] Qureshi B. Cultural gynaecomastia. Lancet 1997;350:1108. [10] Dayal D, Bhalla AK, Sachdeva N. A boy with prepubertal gynecomastia, hyperprolactinemia, and hypothyroidism. J Pediatr Endocrinol Metab 2013;26:357–360. [11] Raveenthiran V. Neonatal mastauxe (breast enlargement of the newborn). J Neonatal Surg 2013;2:31. [12] Ramachandraiah A. Neonatal mastitis. Indian Pediatr 2000;37:1021. [13] Karagol BS, Karadag N, Dursun A, Okumus N, Zenciroglu A. Breast massage and neonatal mastitis: a case report. Cocuk Dergisi 2012;12:95–97. [14] Borders H, Mychaliska G, Gebarski KS. Sonographic features of neonatal mastitis and breast abscess. Paeditric Radiol 2009;39:955–958. [15] Panteli C, Arvaniti M, Zavitsanakis A. Long-term consequences of neonatal mastitis. Arch Dis Child 2012;97:673–674. [16] Kaplowitz PB, Mehra R. Clinical characteristics of children referred for signs of early puberty before age 3. J Pediatr Endocrinol Metab 2015;28:1139–1144. [17] Kinsella Jr C, Landfair A, Rottgers SA, Cray JJ, Weidman C, Deleyiannis FW, et al. The psychological burden of idiopathic adolescent gynecomastia. Plast Reconstr Surg 2012;129:1–7. [18] Plan International and WHO. Protecting children from harmful practices in plural legal systems with a special emphasis on Africa;New York 2012.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/pepo
Case report/Kazuistyka
Cultural gynecomastia in the 21st century India: “Witch's milk” revisited Devi Dayal 1,*, Vimlesh Soni 1, Dhaarani Jayaraman 1, Lakshminarasimhan Sindhuja 1, Naresh Sachdeva 2 1 2
Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
article info
abstract
Article history:
Despite the common cultural practice of expressing breast milk in neonates, the resul-
Received: 23.03.2016
ting gynecomastia is rarely reported probably because it is considered benign and short
Accepted: 25.04.2016
lasting. To determine the clinical course of gynecomastia–galactorrhea resulting from the
Available online: 04.05.2016
cultural practice of expressing breast milk, we performed a retrospective analysis of data
Keywords: Gynecomastia
hospital over the past decade. The mean age at presentation and at the time of first
Galactorrhea Cultural practices
days) respectively. The average duration of breast manipulation was 39.0 66.9 days
of 20 infants (14 girls) diagnosed as cultural gynecomastia at a tertiary care pediatric
Witch's milk Neonatal breast manipulation
noticing was 8.0 9.3 months (range 0.25–27 months) and 54.6 93.9 days (range 2–365 (range 3–270 days). All infants cried during the process of breast manipulation. The mean age at complete resolution was 16.9 8.9 months (range 4–36 months). Gynecomastia resulting from the cruel cultural practice of milking of neonatal breasts exists in modern times and may persist for long time during infancy. © 2016 Polish Pediatric Society. Published by Elsevier Sp. z o.o. All rights reserved.
Introduction Enlargement of breasts occurs in approximately 70% of normal neonates and is considered physiological [1]. It is probably caused by hyperprolactinemia secondary to the falling levels of maternally transferred estrogens in the neonate [1]. The breast enlargement may considerably vary in size but the palpable breast tissue (PBT) usually measures <2 cm [2]. Hyperprolactinemia may also stimulate the
breasts to produce milk commonly referred to as “Witch's milk” [3]. These two physiological phenomena of breast enlargement and milk secretion are usually self limited but may sometimes persist till 2 months of age [4, 5]. However, repeated manual emptying of glands may result in continued milk secretion for up to 24 weeks, and significant increase in PBT which may persist for a variable period during infancy [5, 6]. Although manual expression of breast milk is common in many countries as an unhealthy cultural practice that probably had its origin from the superstitions
* Corresponding author at: Pediatric Endocrinology & Diabetes Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India. Tel.: +91 172 2755657/2772777; fax: +91 172 2744401/2745078. E-mail addresses: [email protected], [email protected] (D. Dayal). http://dx.doi.org/10.1016/j.pepo.2016.04.010 0031-3939/© 2016 Polish Pediatric Society. Published by Elsevier Sp. z o.o. All rights reserved.
pediatria polska 91 (2016) 472–475
related to witch's milk [6–9], reports on the clinical course of the resultant gynecomastia and/or galactorrhea are rare [6]. Also, it is not known if the PBT regresses completely or residual gynecomastia persists. With an aim to understand their presentation and follow up course, we retrospectively analyzed the clinic records of children diagnosed to have this condition at our center.
Materials and methods Cultural gynecomastia was defined as the occurrence of bilateral gynecomastia (average PBT >4 cm diameter) and/or galactorrhea as a result of cultural practice of milking of breasts of neonates of either sex [6, 9]. Data regarding the age the at time of noticing by parents and at diagnosis, number of days and reasons (custom/belief) of breast manipulation, diameter of PBT at presentation, pigmentation of areola and nipples, hormonal profiles if available, age at complete resolution, and presence of residual gynecomastia if any, were extracted from the clinic files. Those with unilateral gynecomastia, any evidence of infection or nipple discharge other than milk and a known etiology for prepubertal gynecomastia [10] were not included in the analysis. The educational and socioeconomic status (SES) of parents was recorded.
Results Twenty children who attended the Pediatric Endocrinology Clinic of our tertiary care teaching hospital located in Northwest India, between April 2004 and April 2015 were diagnosed to have cultural gynecomastia. Girls (14, 70%) outnumbered boys. The mean age at presentation was 8.0 9.3 months (range 0.25–27 months) and at the time of first noticing by parents were 54.6 93.9 days (range 2–365 days). The reasons for seeking medical advice were nonresolution of gynecomastia/galactorrhea, social embarrassment or parental anxiety regarding some underlying problem. The average duration of breast manipulation was 39.0 66.9 days (range 3–270 days). The exact reason for breast squeezing was not known to most mothers (14, 70%) who just followed the grandmother or the midwives’ advice blindly and performed this like a customary practice. Others (6, 30%) tried to suggest that they followed the custom due to the prevalent belief that breasts will not become prominent at the time of puberty which is considered indecorous in large families. The process of breast manipulation to express milk was considered to cause pain as crying during the process occurred in all infants. The mean PBT diameter at presentation was 4.4 0.4 (range 4–6 cm) on either side (Fig. 1). Pigmentation of areola and nipple was not seen in any patient. Galactorrhea was present in 15 (75%) patients. Hormonal profiles were obtained in 10 patients only, mainly on parental insistence. The mean levels of luteinizing hormone (LH), follicle stimulating hormone (FSH), estradiol (E2) and prolactin (PRL) were 0.71 1.8 mIU/mL (range 0.1–5.8 mIU/mL, normal 0.02– 0.3 mIU/mL), 4.9 3.4 mIU/mL (range 2.61–14.3 mIU/mL,
473
normal 0.26–4.2 mIU/mL), 14.2 14.8 (range 5.0–49.5, normal <30 pg/mL), and 17.8 10.8 ng/mL (range 7.7–39.4, normal 3–24 ng/mL) respectively. No intervention other than a firm advice to stop expressing milk was done in any patient. Repeat hormonal estimations after 3–6 months in 3 children with abnormal initial results (LH 2, FSH 2, E2 1, PRL 3) were within normal ranges. The mean age at complete resolution was 16.9 8.9 months (range 4–36 months). The mean duration of follow up was 25.1 11.9 months (range 12–55 months). Nine (45%) families belonged to lower, 10 (50%) to middle and 1 (5%) to upper SES. All mothers were educated up to primary (6, 30%), high school (4, 20%), secondary school (5, 25%), and graduation (3, 15%) or post graduation (2, 10%).
Discussion The cultural practice of manipulation of the newborn baby's breasts to express what is popularly called Witch's milk, is centuries old [3]. The twin phenomena of neonatal breast enlargement and milk secretion were first recorded in the 17th century at a time when superstitions prevailed over reasoning [3]. According to one superstition, some women were accused of having sold their souls to Satan in return for the gift of supernatural powers and were referred to as witches and believed to victimize babies by suckling their mammary glands and leaving the “Witches’ marks”. The custom of expressing milk from the neonate's breasts probably originated from the lingering superstitions regarding witch's milk [3]. Midwives and grandmothers believed that if witch's milk were not frequently and thoroughly expressed from the baby's mammary glands, it would be stolen by witches and goblins. Another belief was that the formation of milk from the babies’ breasts was induced by evil spirits, goblins, or imps to provide themselves with a source of nourishment, and that this bad milk must be sucked out [3]. In India, it is a customary practice to milk a neonate's breasts everyday from the age of 7 days up to the age of 7 weeks or until milk ceases to be expressed [6, 9]. It is believed that this expression of milk in the neonatal life does not allow the breasts to become prominent before the popular age for arranged marriage. Large breasts at an earlier age (usual age of onset of puberty) are considered inappropriate in extended Hindu families [9]. While this harmful cultural practice became extinct from the developed countries after the advent of modern science, it persists in the less developed countries even today [3, 6–9]. In a study from Jamaica on cultural beliefs and practices, squeezing of neonatal breasts to express milk was practiced by 52.2% of mothers [7]. In a recent series from North India, a prior history of manual expression of breast secretions was recorded in 15 out of 32 neonates who developed mastitis or breast abscesses [8]. Other authors from India have referred to this as a common practice especially in rural areas [11, 12]. Parents seek medical advice only if the gynecomastia/galactorrhea does not regress as expected, feel social embarrassment of having an infant with enlarged breasts, or develop anxiety about an underlying problem. Our patients also were brought after an average gap of
474
pediatria polska 91 (2016) 472–475
Fig. 1 – Infants aged 1–1½ yrs showing breast enlargement
approximately 6 months from onset of the condition. The affected babies belonged to all SESs and mothers’ educational status had little impact on this customary practice. The practice of milking the neonatal breasts is potentially harmful. Although infective complications were not noted in the earlier studies [5], recent reports suggest this practice to be a common underlying factor for development of neonatal mastitis or abscess [8, 11–14]. The infection is usually localized to breasts but may result in complications such as cellulitis, fasciitis, osteomyelitis, brain abscess and sepsis [11, 13]. Additionally, girls treated for neonatal mastitis as infants may show poor pubertal development of breast tissue [15]. The enlarged breasts during infancy cause social embarrassment and worry about an underlying etiology as reported by the parents. The persistence of gynecomastia till the mean age of 16.9 months in our patients was probably a result of continued breast stimulation. Cultural gynecomastia closely resembles isolated premature thelarche which is another common and usually
benign condition during early childhood [16]. A significant history of breast manipulation during early infancy and noticing of breast enlargement almost simultaneously or within a short period after manipulation, strongly favors a diagnosis of cultural gynecomastia. Additionally, cultural gynecomastia is usually noticed during early infancy as seen in our cohort of patients, as compared to isolated premature thelarche which is usually diagnosed after 2 years of age [16]. The practice is of breast manipulation is cruel to the infant as parents reported crying in all babies particularly when vigorous attempts were made in a bid to squeeze out the last few drops of milk from the breasts. The cumulative suffering of pain by the infant over many days or weeks is enormous and should also be perceived as a form of cultural cruelty. One of our patients had to suffer this for 9 months. The residual gynecomastia may be a source of low esteem in a growing child similar to the psychological effects of pubertal gynecomastia [17].
pediatria polska 91 (2016) 472–475
The lack of data on the cultural gynecomastia is intriguing given that the practice of milking of neonatal breasts is common in many countries. It is important to document information on this cultural practice similar to several other more harmful traditional practices that impinge on children's rights [18]. In addition, the evidence on existence and effects of the harmful practices is essential to develop legislative and other measures that will result in a sustained abandonment of such practices against children [18]. In conclusion, the cruel cultural practice of expression of breast milk in neonates exists in modern times and needs to be abandoned. The condition is not always benign and self limiting contrary to previous observations. To the best of our knowledge, this is the first detailed account of cultural gynecomastia from a developing country set up.
Authors’ contributions/Wkład autorów DD – concept and design, preparation of final draft of manuscript. VS – data collection, preparation of initial draft of manuscript. DJ – data analysis, editing and review of first draft of manuscript. SL – literature review, intellectual inputs during preparation of final draft. NS – interpretation of laboratory data.
Conflict of interest/Konflikt interesu None declared.
Financial support/Finansowanie None declared.
Ethics/Etyka The work described in this article have been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans; EU Directive 2010/63/EU for animal experiments; Uniform Requirements for manuscripts submitted to Biomedical journals.
475
references/pi smiennictwo
[1] Amer A, Fischer H. Neonatal breast enlargement. N Engl J Med 2009;360:1445. [2] Jayasinghe Y, Cha R, Horn-Ommen J, O’Brien P, Simmons PS. Establishment of normative data for the amount of breast tissue present in healthy children up to two years of age. J Pediatr Adolesc Gynecol 2010;23:305–311. [3] Forbes TR. Witch's milk and witch's marks. Yale J Biol Med 1950;22:219. [4] Madlon-Kay DJ. ‘Witch's milk’. Galactorrhea in the newborn. Am J Dis Child 1986;140:252–253. [5] Buehring GC. Witch's milk: potential for neonatal diagnosis. Pediatr Res 1982;16:460–462. [6] Devidayal. A male infant with gynecomastia–galactorrhea. J Pediatr 2005;147:712. [7] Tracey-Moodie J. Cultural practices and beliefs of mothers in St. Catherine, Jamaica and how these influence care of their newborn and the implications for the health system. MD dissertation abstract The University of the West Indies at St. Augustine, Trinidad and Tobago; 2001. Available at: http://hdl.handle.net/2139/3851. [8] Masoodi T, Mufti GN, Bhat JI, Lone R, Arshi S, Ahmad SK. Neonatal mastitis: a clinico-microbiological study. J Neonatal Surg 2014;3:2. [9] Qureshi B. Cultural gynaecomastia. Lancet 1997;350:1108. [10] Dayal D, Bhalla AK, Sachdeva N. A boy with prepubertal gynecomastia, hyperprolactinemia, and hypothyroidism. J Pediatr Endocrinol Metab 2013;26:357–360. [11] Raveenthiran V. Neonatal mastauxe (breast enlargement of the newborn). J Neonatal Surg 2013;2:31. [12] Ramachandraiah A. Neonatal mastitis. Indian Pediatr 2000;37:1021. [13] Karagol BS, Karadag N, Dursun A, Okumus N, Zenciroglu A. Breast massage and neonatal mastitis: a case report. Cocuk Dergisi 2012;12:95–97. [14] Borders H, Mychaliska G, Gebarski KS. Sonographic features of neonatal mastitis and breast abscess. Paeditric Radiol 2009;39:955–958. [15] Panteli C, Arvaniti M, Zavitsanakis A. Long-term consequences of neonatal mastitis. Arch Dis Child 2012;97:673–674. [16] Kaplowitz PB, Mehra R. Clinical characteristics of children referred for signs of early puberty before age 3. J Pediatr Endocrinol Metab 2015;28:1139–1144. [17] Kinsella Jr C, Landfair A, Rottgers SA, Cray JJ, Weidman C, Deleyiannis FW, et al. The psychological burden of idiopathic adolescent gynecomastia. Plast Reconstr Surg 2012;129:1–7. [18] Plan International and WHO. Protecting children from harmful practices in plural legal systems with a special emphasis on Africa;New York 2012.